Commentary on
the Royal Australasian College of Physicians'
policy on circumcision

On August 27, 2009, the Royal Australasian College of Physicians forshadowed a new policy on circumcision that is a considerable improvement on the 2004 one. It was not published for nearly a year, in a considerably watered-down form.

Paediatrics & Child Health Division The Royal Australasian College of Physicians

Policy Statement On Circumcision

EXECUTIVE SUMMARY

The Paediatrics & Child Health Division, The Royal Australasian College of Physicians
(RACP) has prepared this statement on circumcision of infant boys for doctors and to
assist parents who are considering having this procedure undertaken on their male
children.

Circumcision of males has been undertaken for religious and cultural reasons for many
thousands of years and it remains an important ritual in some religious and cultural groups.
In Australia and New Zealand, the circumcision rate has fallen in recent years and it is
estimated that currently 10-20% of newborn male infants are circumcised. [Much lower in some states and New Zealand]

Recently there has been renewed debate regarding both the potential health benefits and
the ethical and human rights issues relating to infant male circumcision.

Circumcision is generally a safe procedure but there are risks of minor complications and
some rare but serious complications.

The most important conditions where benefits may result from circumcision are recurrent
urinary tract infections in children; and Human Immunodeficiency Virus (HIV) plus some
other sexually transmitted infections in adults from populations with a high prevalence of
these conditions; cancer of the penis in men with a history of phimosis, and cancer of the
cervix in women whose partners engage in sexual practices known to increase the risk of
Human Papilloma Virus (HPV) infection. The protection against Sexually Transmitted
Infections (STIs) and HIV is less clear-cut in Australia and New Zealand than in high
prevalence countries.

Ethical and human rights concerns have been raised regarding elective infant male
circumcision because it is recognised that the foreskin has a functional role, the operation
is non-therapeutic and the infant is unable to consent.

After reviewing the currently available evidence, the RACP believes that the frequency of
diseases modifiable by circumcision, the level of protection offered by circumcision and the
complication rates of circumcision do not warrant routine infant circumcision in Australia
and New Zealand. However it is reasonable for parents to weigh the benefits and risks of
circumcision and to make the decision whether or not to circumcise their sons.

When parents request a circumcision for their child the medical attendant is obliged to
provide accurate unbiased and up to date information on the risks and benefits of the
procedure. Parental choice should be respected.

When the operation is to be performed it should be undertaken in a safe, child-friendly
environment by an appropriately trained competent practitioner, capable of dealing with
the complications, and using appropriate analgesia.
...

The foreskin has two main functions. Firstly it exists to protect the glans penis. Secondly
the foreskin is a primary sensory part of the penis, containing some of the most sensitive
areas of the penis.[21] The effects of circumcision on sexual sensation however are not
clear, with reports of both enhanced and diminished sexual pleasure following the
procedure in adults and little awareness of advantage or disadvantage in those
circumcised in infancy.[22, 23] Two recent African studies reported no evidence of sexual
disadvantage or dysfunction after adult circumcision.[24, 25] An Australian study of
homosexual men reported that circumcision status did not affect their sexual
experience.[26]

ETHICAL CONSIDERATIONS OF NEONATAL CIRCUMCISION

Circumcision of infant males is a medical procedure. The ethics of this medical procedure
fall within the ethical framework which applies to all medical procedures performed on
children. This framework has 3 main principles: (1) Focus on the child, and their needs and
interests; (2) minimisation of harm to the child (including prevention of
avoidable/unnecessary harm); (3) recognition of the child's parents as the decisionmakers
for the child (on the basis that this best promotes the child's interests and wellbeing).

The standard ethical position is that parents have the right and obligation to make
medical decisions for their child - a right which can only be taken away from parents if
their decision is significantly detrimental to the child. The standard ethical obligations of
doctors are to act in the child's best interests, not cause excessive or avoidable suffering
to a child, and provide the child's parents with information so that they are able to make a
fully informed decision about their child's health care. A basic ethical requirement for
performing a medical procedure on a child is that it can reasonably be expected to
produce more benefits than burdens (in the long term) for the child. [And the rest of this policy indicates that circumcision does not meet this standard.]

Parental reasons for wanting infant male circumcision fall broadly into three categories: (1)
health, (2) hygiene and appearance, and (3) religio-cultural reasons. Depending on their
reasons, parents are aiming to secure different types of benefits for their child: physical
health (medical) benefits, and/or psychosocial benefits of various kinds. The physical
health benefits for a male of being circumcised (e.g. reduced risk of HIV infection) could
largely be obtained by deferring circumcision to a much later age. The psychosocial
benefits that parents seek, including full inclusion and participation in a religious or cultural
community, or fitting in with family and social group norms, often cannot be obtained
unless circumcision is done in the newborn period, as required by the religious or cultural
customs. [The question arises whether medical practitioners should be performing medical proceures with a view to obtaining religious or social outcomes. A parallel case - ignoring issues of severity or safety - is female genital cutting. In April 2010, the AAP considered performing a token ritual nick on girls and rejected it.]

Since circumcision involves physical risks which are undertaken for the sake of
psychosocial benefits or debatable medical benefit to the child, the ethical question is
whether it is ethically justifiable to allow parents to make this decision for their child - or is
it a parental decision which ought to be overridden because it is detrimental to the
interests of the child?

There are analogous situations where parents decide on medical procedures for a child
that involve physical risk to the child, and where the intended benefits are primarily
psychosocial. Cosmetic procedures are an obvious example - e.g. removal of skin lesions,
pinning of ears, re-shaping of the skull. The psychosocial benefits (fitting in, not being
subject to ridicule or exclusion) are often regarded as clearly worth the physical risks of the
procedure. [This analogy fails when we consider that the modifications concerned restore the child to the norm for the whole human race, not just some restricted social group.] Obtaining bone marrow from one child for transplant to a sibling is another clear example of seeking psychosocial benefits (i.e. survival of a sibling) at the risk of physical distress and harm. [This example is strained indeed, when the life and health of the sibling are at stake.] Thus infant male circumcision is not ethically unique. Physical
risk to children is sometimes tolerated for the sake of psychosocial benefit to them. For
infant male circumcision, the issue is whether the risk/benefit ratio is within reasonable
bounds, and hence able to be left to the discretion of parents.

Some of the risks of circumcision are low in frequency but high in impact (death, loss of
penis); others are higher in frequency but much lower in impact (infection, which can be
treated quickly and effectively, with no lasting ill-effects). Low impact risks, when they are
readily correctable, do not carry great ethical significance. Evaluation of the significance of
high-impact low-frequency risks is ethically contentious and variable between individuals.
Some are more risk averse than others. However, a statistical risk of death is not generally
regarded as an absolute barrier. Most patients and most people in general accept the very
low probability of death as a risk they are willing to take in pursuit of medical benefits,
lifestyle, recreation, employment, and so on. [Yes, for themselves, not for other people.] The benefits of circumcision (or
disadvantages of non-circumcision) are not readily assessable by doctors (unless they
happen to belong to the same religious or social community as the parents), as they
depend upon the role of circumcision within that community. [At some point the doctors have to stand, not in loco parentis but in loco infanto, advocating for the child against the parents. Again, consider the case where the child is female, and not only ethics but the law takes the side of the child without equivocation, and absolutely forbids cutting her genitals for the sake of her parents' culture.]

This suggests that parents are in principle better placed than doctors to weigh up the risks
and benefits of circumcision for male infants. It is ethically appropriate for the decision
about infant male circumcision to be left in parents' hands, with the proviso that the
decision may be overridden in individual cases where circumcision poses greater than
average physical risks to the child (for example, because of concurrent morbidities). To
deny parents the option to choose circumcision for their male infant would be to judge that
it is clearly detrimental to a child's overall well being and interests in all circumstances. [Yes, that is pretty much the Intactivist case - because in the case of circumcision, unlike immediately-needed medical procedures, we are not just talking about a "child's" overall well-being and interests, but that of an adult who will enjoy full equality with the adults who are now considering cutting parts off him.]

Parents will need comprehensive, accurate information about the procedure (including
options for how, when and by whom it might be performed), the risks, and how these could
be minimised or managed if they occur. [Only if they plan to circumcise.] The information to be provided legitimately
includes the opinion or recommendation of the doctor. [What is the basis for that claim? Since doctors disagree, the recommendation they get will depend very much on factors that are completely irrelevant to the child, such as the doctor's own circumcision status.] Doctors who have a conscientious
objection to performing infant male circumcision should make this known and refer parents
to another doctor. [Again, the doctor would not have to do this - or even be allowed to do it - if the child were female. The doctor's conscience may very well forbid him referring the baby to another doctor for an operation that he can not in good conscience perform - just as if he declined do to it for the sake of the child's health. And there may not be another doctor willing to do it.]

The option of leaving circumcision until later, when the boy is old enough to make a
decision for himself does need to be raised with parents and considered. This option has
recently been recommended by the Royal Dutch Medical Association.[119] The ethical
merit of this option is that it seeks to respect the child's physical integrity, and capacity for
autonomy by leaving the options open for him to make his own autonomous choice in the
future. However, deferring the decision may not always be the best option. [According to whom?] As noted
earlier, the psychosocial benefits of circumcision (e.g. full inclusion in a religious
community) may only be obtained if circumcision is done in infancy. Waiting until the boy is
twelve years old or more (i.e. old enough to make his own decision) may mean losing
benefits that circumcision was intended to produce. [Intended, but with no guarantee that it will produce those benefits]

Children may grow up to disagree with decisions that parents have made for them when
they were young. This cannot always be prevented or avoided. Some decisions have to be
made at the time. The later disagreement of the child does not show that the parents'
decision at the time was unethical or wrong. Parents and doctors have to decide the basis
of their own evaluations of benefits and burdens, being aware that they are making
predictions and that nothing is guaranteed. A boy circumcised as an infant may deeply
resent this when he grows older; he may want what he cannot have - not to have been
circumcised. [This seems an attempt to put wanting not to have been circumcised into the same category as "wanting the moon". Unlike the moon, the only reason he can not have it is that it's a done deal. There was no reason he had to be circumcised prior to making his opinion known.] But it is also possible that a boy not circumcised as an infant (so that he can make his own decision later), may also deeply resent this. He may also want what he cannot now have - to have been circumcised as a baby. [This is a rather silly argument. Having been left alone as a baby is not on all fours with having been circumcised as a baby. In the one case, what he wanted was something he had had that was by someone else's decision taken away, and more and more men are coming forward to complain about it. There are very few cases of men not being satisfied to be circumcised when and if they want to be.]

[This section seems to have been written by someone desperately trying to justify circumcision.]